Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

Key Points Question What is the prevalence of resident-to-resident aggression (RRA) among residents of assisted living facilities? Findings Data from a cross-sectional study using a probability sample of assisted living facilities in New York state showed that the 1-month prevalence of RRA was estimated to be 15.2%. The most common forms of RRA included verbal, physical, and sexual aggression. Meaning The relatively high prevalence of RRA among residents of assisted living facilities underscores the need for recognition and treatment to avoid serious consequences for residents.


Introduction
More than 800 000 individuals in the US live in 30 600 assisted living facilities with a capacity of 1.2 million beds. 1 Assisted living facilities are settings in which residents typically have better mobility and cognition than in nursing homes, with lower staffing levels.The state survey process is less uniform in assisted living facilities compared with nursing homes.There is no standard definition of assisted living, but the term is typically defined as care settings that provide room and at least 2 meals, assistance with personal care, and round-the-clock supervision. 2st assisted living facility residents are non-Hispanic White (89%), female (67%), and older (55%; aged Ն85 years). 3Relative to nursing homes, fewer assisted living facility residents are covered by Medicaid (19% vs 60%).Nearly two-thirds of assisted living facility residents require assistance with 3 or more activities of daily living (ADLs), and about two-thirds of residents (66%) have received a diagnosis of at least 2 of the 10 most common chronic conditions among older adults.
Alzheimer disease and other dementias are common conditions among assisted living facility residents (42%). 4In response to these levels of dementia, assisted living facilities may apply for special certification to provide care to residents with cognitive impairment.The current size and anticipated growth of the assisted living facility sector has led to increased research on the determinants of the quality of care in these settings.
One underresearched area is a problem that clinical experience suggests is widespread: negative and aggressive interactions among residents.Research on nursing homes shows that resident-to-resident aggression (RRA) is highly prevalent.The most extensive study of RRA in nursing homes 5 found a 1-month prevalence rate of 20.2%.8][9][10][11] The fact that assisted living facilities care for individuals who are impaired in activities of daily living, many of whom have dementia, suggests that RRA may also be prevalent in this population.To date, 1 small-scale study has examined the prevalence of RRA among residents in assisted living facilities.In a sample of 121 residents in 6 assisted living facilities, Trompetter and colleagues 10 found that 19% of the sample reported experiencing what they termed as resident-to-resident relational aggression.Given the lack of other research on this potentially prevalent and harmful phenomenon, there is a need to identify the prevalence of RRA in assisted living facilities.This article provides prevalence estimates from the first large-scale, systematic study of RRA in assisted living facilities.
Our goal was to estimate RRA prevalence, including subtypes of verbal, physical, and sexual aggression, and to examine variations in the prevalence across demographic and other characteristics.

Design
The design of the prevalence study was cross-sectional (NCT03383289).Estimates of prevalence were obtained using baseline data from an interventional study of RRA.The design of the parent study is described elsewhere. 12This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.The study was approved by the Weill Cornell Medicine institutional review board and that of the Hebrew Home at Riverdale.
Residents provided written or witnessed oral consent; for residents unable to complete the written or witnessed oral consent process (eg, due to cognitive impairment, language barrier, or health impairment), consent was sought by designated proxies (families or legal guardians).units.In the downstate sample, there were 50 larger (Ն70 beds) facilities with special needs units.

Recruitment of Facilities
Of 18 facilities randomly selected, 14 agreed to participate, yielding a participation rate of 77.8%.
The relatively high participation rate is in part because these data were collected as part of a clinical trial that offered staff training and in part because of a set of practices that we have used successfully in previous studies, including offering training in RRA intervention to usual care facilities after the data were collected.An honorarium to cover staff time and related costs was provided.In addition, all assisted living communities that we approached perceived RRA as a highly relevant issue to their staff, residents, and families.

Eligible Participants
All long-stay residents (N = 1067) except those in hospice (n = 11) were invited to participate.
Residents unable to respond were excluded from self-reported measures; however, medical record review, staff informant, and observational measures were performed for individuals with proxy consent.Residents who met the exclusion criteria or who died or were discharged prior to enrollment (n = 93) were excluded from the denominator in prevalence estimates.There were 33 family and resident refusals.The sample size totaled 930 residents (360 upstate and 570 downstate), slightly lower than the preplanned sample of 1050.

Procedures
The research team entered each facility for approximately 2 to 3 months and enrolled participants on a rolling basis.A 2-stage cognitive capacity screening test was administered to assess the ability to provide consent for participation in noninvasive research, with a second-stage screening test to assess the ability to provide an extended RRA interview.
Because the protocol was to interview staff first and then residents as soon as possible after the staff interview (usually within 2 weeks), it was necessary to include a 1-month prevalence period to consider reports from both staff and residents.The date of the earliest RRA staff or resident interview (which inquired about events in the prior 2 weeks) bracketed a 1-month period.The staff interview was almost always used to set the index date.For the 57 cases in which only a resident interview was available, that was the index date.Accordingly, event reports, incident reports, and event log data collected during this same 4-week period were selected as potential RRA events by a computer algorithm if they were in the specified date range.Baseline data collection occurred from May 30, 2018, through August 11, 2022.

RRA Measures and Case Finding
A triangulation approach for identification of RRA was used; each component contributed to case finding and overall prevalence estimates.Six methods were used to identify cases of RRA over the observation period.An RRA event is defined as any of the following events occurring during the prevalence periods: Resident RRA Instrument | Residents with sufficient cognitive capability were administered an RRA instrument that inquired about 22 forms of physical, verbal, or sexual events in the prior 2 weeks. 13,14Physical events included 8 items: hitting, kicking, grabbing, pushing, biting, scratching, spitting, and throwing things; verbal events included 5 items: using bad words, screaming, trying to scare with words, bossing you around, and insulting a resident's racial or ethnic group; and sexual

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Prevalence of Resident-to-Resident Aggression in Assisted Living events included 3 items: saying sexual things, doing sexual things in front of you, and touching in a sexual manner.
Staff RRA Instrument | For all consented residents regardless of cognitive status, the primary direct caregiver for the resident was interviewed with the staff version of the instrument. 14A Event Form (Shift Coupon) | Staff completed an RRA event form as events were observed.
This preprinted prescription-sized pad with detachable sheets had basic information about events, and completed forms were deposited in a box at the nursing station.
Observation or Event Log | A small number of events were directly observed by research staff who were continuously stationed in each facility during the study period and were reported in the event logs.In addition, certain events that were described for one participant in an interview were described for the other participant in event logs.
Incident Reports | Facility incident reports were reviewed over the prevalence period for episodes of RRA.

Covariates
Covariate data were collected to assess whether selected participant, environmental, and facility characteristics were associated with RRA.6][17] This 14-item measure permits 5 classifications of cognitive impairment: none, mild, moderate, severe, and very severe.The Cronbach α coefficient estimated for this sample was 0.87 (ordinal α was 0.94), and the McDonald ω total estimate from a single common factor model was 0.94.The main source of race and ethnicity data was the resident record reviews and, if missing, from the resident interview.The categories were Asian, Black, Hispanic, and White.
In the prior study of RRA prevalence in nursing homes, all RRA events, irrespective of reporting source, underwent a case conference and adjudication process developed for the study. 5The purpose of this process was (1) to achieve consensus on cases of RRA that were deemed by 1 or more investigators to be equivocal and (2) to designate a "primary" (ie, most egregious, with the highest risk for harm) form of RRA when multiple types of RRA occurred over the prevalence period.Because it was observed that the agreement was high and the final designation almost always matched what was reported in the resident or staff interview, for this study, case conferencing was not performed.

Statistical Analysis
The χ 2 test of significance with SE adjustments for clustering was conducted for comparison of subgroup rates.To estimate prevalence rates, the SPSS Complex Samples Tabulate command in SPSS, version 28.0 (SPSS Inc) was used 18 ; 95% CIs were calculated for each estimate.Estimates were adjusted for clustering within units and staff reporters.Estimates from a generalized linear models module 19,20 were obtained in sensitivity analyses assuming a binomial distribution with a logit link, with inclusion of random effects for unit and staff.Sample size was determined for the clinical trial.
Subtypes of RRA (physical, verbal, and sexual) were similarly calculated with adjustments for clustering.The 1-month and annual prevalences (inclusive of 1 month) were estimated.The rates for subtypes were not mutually exclusive.The rates for verbal subtypes were somewhat higher because some residents engaged in verbal RRA in addition to physical, sexual, or other RRA.There were 51 units and 195 staff members.The mean (SD) unit cluster size was 18.2 (12.5) residents per unit.The mean (SD) cluster size for staff was 4.8 (9.5) residents per staff member; the median was 2 (IQR, 1-5).As in previous analyses of this type, the facility variance component was estimated at 0 and was not significant.The variance component from the random-effects model for unit was not significant; the variance component for staff members was significant.The intracluster correlation coefficient was 0.127 for unit and 0.261 for staff.Given the relatively high intracluster correlation coefficient for unit, it was decided to retain both unit and staff as random effects to model the clustering induced by residents clustered within units and within staff members.

Prevalence Estimates
Prevalence estimates were examined across 2 time periods: 1 month and annual prevalences (inclusive of 1 month) were estimated during the stay at the facility.As shown in   3).
Ambulation ability was also associated significantly with RRA (18.5% [114 of 616] vs 10.6% [21 of 198]   among those who did not ambulate).c The interview season is a proxy for the event season for the 1-month lookback period.

JAMA Network Open | Geriatrics
Prevalence of Resident-to-Resident Aggression in Assisted Living

JAMA Network Open | Geriatrics
Random samples of 6 licensed assisted living residences in New York City, Westchester County, and Long Island (referred to as downstate) and 8 licensed assisted living residences in upstate New York An aim of the study was to examine RRA among all residents, including those with Alzheimer disease.Therefore, to maximize resources, the sample was restricted to larger facilities with special units for residents with Alzheimer disease and other cognitive impairments as reported by the New York state listing of assisted living facilities.In the upstate sample, we selected from the population of 33 facilities with bed sizes of 50 or more with special needs (memory care) To compare rates by resident characteristics and contextual variables, we estimated rates for the total sample and by downstate and upstate status, sex, age, cognitive status, vision, hearing, ambulation, wheelchair use, unit type, type of room, and season.Based on prior literature on RRA, these factors were considered likely to be associated with RRA prevalence.Rates for downstate and upstate assisted living facilities were not significantly different; thus, the pooled sample was used in subgroup analyses.All statistical tests were 2-sided, and statistical significance was assessed at P < .05.

Table 3
also shows prevalence rates by selected demographic, functional, and cognitive characteristics.As shown, rates were not significantly different across groups differing on sex, age, and cognitive status.For example, 18.0% of those younger than 85 years of age (47 of 261) vs 14.1%

Table 3 .
One-Month Prevalence Estimates by Resident, Region, Facility, and Unit Characteristics Percentages are nonduplicated cases and are adjusted for clustering within staff member and unit.Percentages are in reference to each category.Significant comparisons based on the χ 2 test with adjustment for clustering as follows: no visual impairment or slight visual impairment vs moderate or severe visual impairment or blind (P < .001);no hearing impairment or slight hearing impairment vs moderate or severe hearing impairment or deaf (P = .007);ambulation status (P = .005);and residing on memory care unit (P < .001).
a b